University of Maine System

Transcription

1 University of Maine System OPEN ACCESS PLUS MEDICAL BENEFITS Retiree Only Plan Quality Incentive Passive Plan EFFECTIVE DATE: January 1, 2012 ASO This document printed in September, 2012 takes the place of any documents previously issued to you which described your benefits. Printed in U.S.A.

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3 Table of Contents Important Information...5 Special Plan Provisions...7 Case Management...7 Important Notices...8 How To File Your Out-of-Network Claim...8 Eligibility - Effective Date...9 Employee Insurance...9 Dependent Insurance...9 Open Access Plus Medical Benefits...10 The Schedule...10 Certification Requirements - Out-of-Network...28 Prior Authorization/Pre-Authorized...28 Covered Expenses...28 Prescription Drug Benefits...37 The Schedule...37 Covered Expenses...39 Limitations...39 Your Payments...39 Exclusions...40 Reimbursement/Filing a Claim...40 Exclusions, Expenses Not Covered and General Limitations...40 Coordination of Benefits...42 Expenses For Which A Third Party May Be Responsible...45 Payment of Benefits...46 Termination of Insurance...46 Employees...46 Dependents...46 Rescissions...46 Federal Requirements...47 Notice of Provider Directory/Networks...47 Qualified Medical Child Support Order (QMCSO)...47 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA)...47 Coverage of Students on Medically Necessary Leave of Absence...49 Eligibility for Coverage for Adopted Children...49 Coverage for Maternity Hospital Stay...49 Women s Health and Cancer Rights Act (WHCRA)...49 Group Plan Coverage Instead of Medicaid...50 Obtaining a Certificate of Creditable Coverage Under This Plan...50 Medical - When You Have a Complaint or an Appeal...50

4 COBRA Continuation Rights Under Federal Law...52 Definitions...54

5 Important Information THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY UNIVERSITY OF MAINE SYSTEM WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CONNECTICUT GENERAL PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CONNECTICUT GENERAL DOES NOT INSURE THE BENEFITS DESCRIBED. THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CONNECTICUT GENERAL. BECAUSE THE PLAN IS NOT INSURED BY CONNECTICUT GENERAL, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CG," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE." ASO1

6 Explanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate. The Schedule The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.

7 Special Plan Provisions When you select a Participating Provider, the cost for medical services provided will be less than when you select a non- Participating Provider. Participating Providers include Physicians, Hospitals and Other Health Care Professionals and Other Health Care Facilities. Consult your Physician Guide for a list of Participating Providers in your area. Participating Providers are committed to providing you and your Dependents appropriate care while lowering medical costs. Services Available in Conjunction With Your Medical Plan The following pages describe helpful services available in conjunction with your medical plan. You can access these services by calling the toll-free number shown on the back of your ID card. FPINTRO4V1 CIGNA'S Toll-Free Care Line CIGNA's toll-free care line allows you to talk to a health care professional 24 hours per day, 7 days per week, simply by calling the toll-free number shown on your ID card. CIGNA's toll-free care line personnel can provide you with the names of Participating Providers. If you or your Dependents need medical care, you may consult your Physician Guide which lists the Participating Providers in your area or call CIGNA's toll-free number for assistance. If you or your Dependents need medical care while away from home, you may have access to a national network of Participating Providers through CIGNA's Away-From-Home Care feature. Call CIGNA's toll-free care line for the names of Participating Providers in other network areas. Whether you obtain the name of a Participating Provider from your Physician Guide or through the care line, it is recommended that prior to making an appointment you call the provider to confirm that he or she is a current participant in the Open Access Plus Program. outpatient, or an inpatient in a Hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis. Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your Dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-todate treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending Physician remains responsible for the actual medical care. 1. You, your dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday. In addition, your employer, a claim office or a utilization review program (see the PAC/CSR section of your certificate) may refer an individual for Case Management. 2. The Review Organization assesses each case to determine whether Case Management is appropriate. 3. You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works. Participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management. FPCM6 FPCCL10V1M Case Management Case Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an 4. Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternate treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternate treatment program is not followed. 5. The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing 7

8 services or a Hospital bed and other Durable Medical Equipment for the home). 6. The Case Manager also acts as a liaison between the insurer, the patient, his or her family and Physician as needed (for example, by helping you to understand a complex medical diagnosis or treatment plan). 7. Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient's needs. While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, costeffective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need. FPCM2 Additional Programs We may, from time to time, offer or arrange for various entities to offer discounts, benefits, or other consideration to our members for the purpose of promoting the general health and well being of our members. We may also arrange for the reimbursement of all or a portion of the cost of services provided by other parties to the Policyholder. Contact us for details regarding any such arrangements. GM6000 NOT160 Important Information About Your Medical Plan Details of your medical benefits are described on the following pages. Opportunity to Select a Primary Care Physician Choice of Primary Care Physician: This medical plan does require that you select a Primary Care Physician but does not require you to obtain a referral from a Primary Care Physician in order to receive all benefits available to you under this medical plan. Notwithstanding, a Primary Care Physician may serve an important role in meeting your health care needs by providing or arranging for medical care for you and your Dependents. For this reason, we encourage the use of Primary Care Physicians and provide you with the opportunity to select a Primary Care Physician from a list provided by CG for yourself and your Dependents. If you choose to select a Primary Care Physician, the Primary Care Physician you select for yourself may be different from the Primary Care Physician you select for each of your Dependents. Changing Primary Care Physicians: You may request a transfer from one Primary Care Physician to another by contacting us at the member services number on your ID card. In addition, if at any time a Primary Care Physician ceases to be a Participating Provider, you or your Dependent will be notified for the purpose of selecting a new Primary Care Physician, if you choose. NOT123 Important Notices How To File Your Out-of-Network Claim The prompt filing of any required claim form will result in faster payment of your claim. Your In Network Physician or Hospital will file claims for you. You may get the required claim forms from your Benefit Plan Administrator. All fully completed claim forms and bills should be sent directly to your servicing CG Claim Office. Depending on your Group Insurance Plan benefits, file your claim forms as described below. Hospital Confinement If possible, get your Group Medical Insurance claim form before you are admitted to the Hospital. This form will make your admission easier and any cash deposit usually required will be waived. If you have a Benefit Identification Card, present it at the admission office at the time of your admission. The card tells the Hospital to send its bills directly to CG. Doctor's Bills and Other Medical Expenses The first Medical Claim should be filed as soon as you have incurred covered expenses. Itemized copies of your bills should be sent with the claim form. If you have any additional bills after the first treatment, file them periodically. CLAIM REMINDERS BE SURE TO USE YOUR MEMBER ID AND ACCOUNT NUMBER WHEN YOU FILE CG'S CLAIM FORMS, OR WHEN YOU CALL YOUR CG CLAIM OFFICE. YOUR MEMBER ID IS THE ID SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. V1M 8

9 YOUR ACCOUNT NUMBER IS THE 7-DIGIT POLICY NUMBER SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. PROMPT FILING OF ANY REQUIRED CLAIM FORMS RESULTS IN FASTER PAYMENT OF YOUR CLAIMS. WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinement in prison. GM6000 CI 3 Accident and Health Provisions CLA9V41 M Timely Filing of Out-of-Network Claims CG will consider claims for coverage under our plans when proof of loss (a claim) is submitted within 180 days for Outof-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Outof-Network benefits, the claim will not be considered valid and will be denied. GM6000 P 1 Eligibility - Effective Date CLA65 Eligibility For Employee Insurance You will become eligible for insurance on the date you retire if you are in a Class of Eligible Employees. Eligibility for Dependent Insurance You will become eligible for Dependent insurance on the later of: the day you become eligible for yourself; or the day you acquire your first Dependent. any Dependents added due to the special enrollment rights, their coverage begins the first of the month following the election. Classes of Eligible Employees Each retired Employee as reported to the insurance company by your former Employer. Employee Insurance This plan is offered to you as a retired Employee. To be insured, you will have to pay part of the cost. Effective Date of Your Insurance You will become insured on the date you elect the insurance by signing a written agreement with the Policyholder to make the required contribution, but no earlier than the date you become eligible. To be insured for these benefits, you must elect the insurance for yourself no later than 30 days after your retirement. GM6000 EF 1 ELI7V82 M Dependent Insurance For your Dependents to be insured, you will have to pay part of the cost of Dependent Insurance. Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by signing a written agreement with the Policyholder to make the required contribution, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. For your Dependents to be insured for these benefits, you must elect the Dependent insurance for yourself no later than 30 days after you become eligible. Your Dependents will be insured only if you are insured. Exception for Newborns Any Dependent child born while you are insured for Medical Insurance will become insured for Medical Insurance on the date of his birth if you elect Dependent Medical Insurance no later than 31 days after his birth. If you do not elect to insure your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable. GM6000 EF 2 ELI11V44 M GM6000 EL 2 V-31 ELI5 M 9

10 For You and Your Dependents Open Access Plus Medical Benefits The Schedule Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open Access Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Copayment, Deductible or Coinsurance. If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-of- Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, benefits for those services will be covered at the In-Network benefit level. Coinsurance The term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to pay under the plan. Copayments/Deductibles Copayments are expenses to be paid by you or your Dependent for covered services. Deductibles are also expenses to be paid by you or your Dependent. Deductible amounts are separate from and not reduced by Copayments. Copayments and Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached, you and your family need not satisfy any further medical deductible for the rest of that year. Out-of-Pocket Expenses Out-of-Pocket Expenses are Covered Expenses incurred for In-Network and Out-of-Network charges that are not paid by the benefit plan because of any: Coinsurance. Plan deductibles. inpatient facility deductibles. Charges will not accumulate toward the Out-of-Pocket Maximum for Covered Expenses incurred for: non-compliance penalties. provider charges in excess of the Maximum Reimbursable Charge. When the Out-of-Pocket Maximum shown in The Schedule is reached, Injury and Sickness benefits are payable at 100% except for: non-compliance penalties. provider charges in excess of the Maximum Reimbursable Charge. Accumulation of Plan Deductibles and Out-of-Pocket Maximums Deductibles and Out-of-Pocket Maximums will cross-accumulate (that is, In-Network will accumulate to Out-of-Network and Out-of-Network will accumulate to In-Network). All other plan maximums and service-specific maximums (dollar and occurrence) also cross-accumulate between In- and Out-of-Network unless otherwise noted. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery. 10

11 Assistant Surgeon and Co-Surgeon Charges Assistant Surgeon Open Access Plus Medical Benefits The Schedule The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed 20 percent of the surgeon s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts). Co-Surgeon The maximum amount payable will be limited to 62.5 percent of the surgeon s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeons prior to any reductions due to coinsurance or deductible amounts.) BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Lifetime Maximum Unlimited Coinsurance Levels 80% 80% 80% of the Maximum Reimbursable Charge 11

12 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Maximum Reimbursable Charge Maximum Reimbursable Charge is determined based on the lesser of the provider s normal charge for a similar service or supply; or A percentage of a schedule that we have developed that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for similar services within the geographic market. In some cases, a Medicare based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of: the provider s normal charge for a similar service or supply; or the 80th percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by the Insurance Company. Note: The provider may bill you for the difference between the provider s normal charge and the Maximum Reimbursable Charge, in addition to applicable deductibles, copayments and coinsurance. USM Preferred Provider CIGNA Provider Not Applicable Not Applicable 200% 12

13 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Calendar Year Deductible Individual $300 per person $300 per person $300 per person Family Maximum $600 per family $600 per family $600 per family Family Maximum Calculation Individual Calculation: Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Out-of-Pocket Maximum Individual $1,100 per person $1,100 per person $1,100 per person Family Maximum $2,200 per family $2,200 per family $2,200 per family Family Maximum Calculation Individual Calculation: Family members meet only their individual Outof-Pocket and then their claims will be covered at 100%; if the family Outof-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%. 13

14 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Physician s Services Primary Care Physician s Office visit 85% after plan deductible 80% after plan deductible 80% after plan deductible Specialty Care Physician s Office Visits Consultant and Referral Physician s Services Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. 80% after plan deductible 80% after plan deductible 80% after plan deductible Surgery Performed In the Physician s Office 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible Second Opinion Consultations (provided on a voluntary basis) 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible Allergy Treatment/Injections 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible Allergy Serum (dispensed by the Physician in the office) 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible 14

15 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Preventive Care Routine Preventive Care - all ages Immunizations - all ages No charge No charge No charge No charge No charge No charge Note: Includes immunizations specific to travel. Mammograms, PSA, PAP Smear Preventive Care Related Services (i.e. routine services) No charge No charge No charge Diagnostic Related Services (i.e. non-routine services) Subject to the plan s x-ray & lab benefit; based on place of service Subject to the plan s x-ray & lab benefit; based on place of service Subject to the plan s x-ray & lab benefit; based on place of service Inpatient Hospital - Facility Services 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Semi-Private Room and Board Limited to the semi-private room negotiated rate Limited to the semi-private room negotiated rate Limited to the semi-private room rate Private Room Limited to the semi-private room negotiated rate Limited to the semi-private room negotiated rate Limited to the semi-private room rate Special Care Units (ICU/CCU) Limited to the negotiated rate Limited to the negotiated rate Limited to the ICU/CCU daily room rate Outpatient Facility Services Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room Inpatient Hospital Physician s Visits/Consultations 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 15

16 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Inpatient Hospital Professional Services 80% after plan deductible 80% after plan deductible 80% after plan deductible Surgeon Radiologist Pathologist Anesthesiologist Outpatient Professional Services 80% after plan deductible 80% after plan deductible 80% after plan deductible Surgeon Radiologist Pathologist Anesthesiologist 16

17 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Emergency and Urgent Care Services Physician s Office Visit Hospital Emergency Room 85% after plan deductible (PCP), 80% after plan deductible (Specialist) $100 per visit copay*, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per visit copay*, then 80% after plan deductible $100 per visit copay*, then 80% after plan deductible *waived if admitted *waived if admitted *waived if admitted Outpatient Professional services (radiology, pathology and ER Physician) 80% after plan deductible 80% after plan deductible 80% after plan deductible Urgent Care Facility or Outpatient Facility $25 per visit copay*, then 80% after plan deductible $25 per visit copay*, then 80% after plan deductible $25 per visit copay*, then 80% after plan deductible *waived if admitted *waived if admitted *waived if admitted X-ray and/or Lab performed at the Emergency Room/Urgent Care Facility (billed by the facility as part of the ER/UC visit) Independent x-ray and/or Lab Facility in conjunction with an ER visit Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.) 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible Ambulance 80% after plan deductible 80% after plan deductible 80% after plan deductible 17

18 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub-Acute Facilities Calendar Year Maximum: 100 days combined 80% after plan deductible 80% after plan deductible 80% after plan deductible Laboratory and Radiology Services (includes pre-admission testing) Physician s Office Visit Outpatient Hospital Facility Independent X-ray and/or Lab Facility 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans and PET Scans) Physician s Office Visit 85% after plan deductible (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible 18

19 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Outpatient Short-Term Rehabilitative Therapy and Chiropractic Services 80% after plan deductible 80% after plan deductible 80% after plan deductible Calendar Year Maximum: Unlimited Includes: Cardiac Rehab Physical Therapy Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy Chiropractic Therapy (includes Chiropractors) Home Health Care Calendar Year Maximum: Unlimited (includes outpatient private nursing when approved as medically necessary) 80% after plan deductible 80% after plan deductible 80% after plan deductible Hospice (includes respite care) Inpatient Services 80% 80% 80% Outpatient Services 80% 80% 80% Bereavement Counseling Services provided as part of Hospice Care Inpatient 80% 80% 80% Outpatient 80% 80% 80% Services provided by Mental Health Professional Covered under Mental Health Benefit Covered under Mental Health Benefit Covered under Mental Health Benefit 19

20 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Maternity Care Services Initial Visit to Confirm Pregnancy Note: OB/GYN providers will be considered either a PCP or Specialist depending on how the provider contracts with the Insurance Company. USM Preferred Provider 85% after plan deductible (PCP), 80% after plan deductible (Specialist) CIGNA Provider 80% after plan deductible 80% after plan deductible All subsequent Prenatal Visits, Postnatal Visits and Physician s Delivery Charges (i.e. global maternity fee) 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Office Visits that are not already included in the global maternity fee when performed by an OB/GYN or Specialist 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible Delivery - Facility (Inpatient Hospital, Birthing Center) Abortion Includes elective and nonelective procedures 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Physician s Office Visit 85% after plan deductible (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible 20

21 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Note: The standard benefit will include coverage for contraceptive devices (e.g. Depo-Provera and Intrauterine Devices (IUDs). Diaphragms will also be covered when services are provided in the physician s office. Surgical Sterilization Procedure for Vasectomy/Tubal Ligation 85% after plan deductible (PCP), 80% after plan deductible (Specialist) 80% after plan deductible 80% after plan deductible Physician s Office Visit 85% after plan deductible (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible 21

22 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Infertility Treatment Services Not Covered include: Not Covered Not Covered Not Covered Testing performed specifically to determine the cause of infertility. Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition). Artificial means of becoming pregnant (e.g. Artificial Insemination, In-vitro, GIFT, ZIFT, etc). Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness. 22

23 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Organ Transplants Includes all medically appropriate, nonexperimental transplants Physician s Office Visit 85% after plan deductible 80% after plan deductible In-Network coverage only (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible 100% at Lifesource center, otherwise 80% after $100 per admission copay and plan deductible In-Network coverage only Physician s Services 80% after plan deductible 100% at Lifesource center, otherwise 80% after plan deductible In-Network coverage only Lifetime Travel Maximum: $10,000 per transplant 80% after plan deductible No charge (only available when using Lifesource facility) In-Network coverage only 23

24 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Durable Medical Equipment Calendar Year Maximum: Unlimited Note: must use Cigna approved vendor for Innetwork benefits External Prosthetic Appliances (Includes othotics and arch supports) Calendar Year Maximum: Unlimited Note: must use Cigna approved vendor for Innetwork benefits Consumable Medical Supplies (Includes compression stockings) 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible Note: must use Cigna approved vendor for Innetwork benefits Nutritional Evaluation Calendar Year Maximum: 3 visits per person Physician s Office Visit 85% after plan deductible (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible 24

25 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Dental Care Limited to charges made for a continuous course of dental treatment started within six months of an injury to sound, natural teeth. Note: Includes removing impacted or unerupted teeth in a non-hospital or nonrural health center setting; removing seven or more permanent teeth; Gingivectomies; Osseous surgery; setting of jaw fracture, removal of tumor or cyst; dental services needed as a result of chemotherapy; repairing or replacing dental prostheses due to accidental injury Physician s Office Visit 85% after plan deductible (PCP), 80% after plan deductible (Specialist) Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible 25

26 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Obesity/Bariatric Surgery Note: Coverage is provided subject to medical necessity and clinical guidelines subject to any limitations shown in the Exclusions, Expenses Not Covered and General Limitations section of this certificate. Physician s Office Visit 85% after plan deductible (PCP), otherwise 80% after plan deductible Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible 80% after plan deductible 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible Reversal of Voluntary Sterilization Physician s Office Visit 85% after plan deductible (PCP), otherwise 80% after plan deductible No charge after the $20 PCP or $20 Specialist per office visit copay 80% after plan deductible Inpatient Facility 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Physician s Services 80% after plan deductible 80% after plan deductible 80% after plan deductible Acupuncture Eye Care Services 85% after plan deductible (PCP), otherwise 80% after plan deductible 80% after plan deductible 80% after plan deductible 100% 100% 100% Maximum: One eye exam every 12 months up to age 18, then one every 24 months 26

27 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK USM Preferred Provider CIGNA Provider Hearing Aids 80% after plan deductible 80% after plan deductible 80% after plan deductible Note: Covered once every 36 months up to age 18 Wigs 80% after plan deductible 80% after plan deductible 80% after plan deductible Christian Science Sanitoriums 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Routine Foot Disorders Not covered except for services associated with foot care for diabetes and peripheral vascular disease. Not covered except for services associated with foot care for diabetes and peripheral vascular disease. Not covered except for services associated with foot care for diabetes and peripheral vascular disease. Treatment Resulting From Life Threatening Emergencies Medical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expense until the medical condition is stabilized. Once the medical condition is stabilized, whether the treatment will be characterized as either a medical expense or a mental health/substance abuse expense will be determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines. Mental Health Inpatient 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient (Includes Individual, Group and Intensive Outpatient) Physician s Office Visit 80% after plan deductible 80% after plan deductible 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible Substance Abuse Inpatient 80% after plan deductible $100 per admission copay, then 80% after plan deductible $100 per admission deductible, then 80% after plan deductible Outpatient (Includes Individual and Intensive Outpatient) Physician s Office Visit 80% after plan deductible 80% after plan deductible 80% after plan deductible Outpatient Facility 80% after plan deductible 80% after plan deductible 80% after plan deductible 27

28 Open Access Plus Medical Benefits Certification Requirements - Out-of-Network For You and Your Dependents Pre-Admission Certification/Continued Stay Review for Hospital Confinement Pre-Admission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the Medical Necessity and length of a Hospital Confinement when you or your Dependent require treatment in a Hospital: as a registered bed patient; for a Partial Hospitalization for the treatment of Mental Health or Substance Abuse; for Mental Health or Substance Abuse Residential Treatment Services. You or your Dependent should request PAC prior to any nonemergency treatment in a Hospital described above. In the case of an emergency admission, you should contact the Review Organization within 48 hours after the admission. For an admission due to pregnancy, you should call the Review Organization by the end of the third month of pregnancy. CSR should be requested, prior to the end of the certified length of stay, for continued Hospital Confinement. Covered Expenses incurred will not include the first $500 of Hospital charges made for each separate admission to the Hospital: unless PAC is received: (a) prior to the date of admission; or (b) in the case of an emergency admission, within 48 hours after the date of admission. Covered Expenses incurred for which benefits would otherwise be payable under this plan for the charges listed below will not include: Hospital charges for Bed and Board, for treatment listed above for which PAC was performed, which are made for any day in excess of the number of days certified through PAC or CSR; and any Hospital charges for treatment listed above for which PAC was requested, but which was not certified as Medically Necessary. GM6000 PAC1 PAC and CSR are performed through a utilization review program by a Review Organization with which CG has contracted. V33 In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this plan, except for the "Coordination of Benefits" section. GM6000 PAC2 Prior Authorization/Pre-Authorized The term Prior Authorization means the approval that a Participating Provider must receive from the Review Organization, prior to services being rendered, in order for certain services and benefits to be covered under this policy. Services that require Prior Authorization include, but are not limited to: inpatient Hospital services; inpatient services at any participating Other Health Care Facility; residential treatment; nonemergency ambulance; or transplant services. GM BPT16 Covered Expenses The term Covered Expenses means the expenses incurred by or on behalf of a person for the charges listed below if they are incurred after that person becomes insured for these benefits. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by CG. Any applicable Copayments, Deductibles or limits are shown in The Schedule. Covered Expenses charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Bed and Board Limit shown in The Schedule. charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided. V9 V14 28

29 charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient. charges made by a Free-Standing Surgical Facility, on its own behalf for medical care and treatment. charges made on its own behalf, by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation Hospital or a subacute facility for medical care and treatment; except that for any day of Other Health Care Facility confinement, Covered Expenses will not include that portion of charges which are in excess of the Other Health Care Facility Daily Limit shown in The Schedule. charges made for Emergency Services and Urgent Care. charges made by a Physician or a Psychologist for professional services. charges made by a Nurse, other than a member of your family or your Dependent's family, for professional nursing service. GM6000 CM5 FLX107V126 charges made for anesthetics and their administration; diagnostic x-ray and laboratory examinations; x-ray, radium, and radioactive isotope treatment; chemotherapy; blood transfusions; oxygen and other gases and their administration. GM6000 CM6 FLX108V745 charges made for a mammogram for women when recommended by a Physician. charges made for an annual Papanicolaou laboratory screening test. charges made for an annual prostate-specific antigen test (PSA). charges for appropriate counseling, medical services connected with surgical therapies, including vasectomy and tubal ligation. charges made for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures. charges made for Family Planning, including medical history, physical exam, related laboratory tests, medical supervision in accordance with generally accepted medical practices, other medical services, information and counseling on contraception, implanted/injected contraceptives. charges made for office visits, tests and counseling for Family Planning services. charges made for the following preventive care services (detailed information is available at endations.html): (1) evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; (3) for infants, children, and adolescents, evidenceinformed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; (4) for women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. GM6000 FLX108V811 charges made for surgical or nonsurgical treatment of Temporomandibular Joint Dysfunction. charges made for acupuncture. a drug prescribed for the treatment of HIV or AIDS, even if the drug has not been approved by the federal Food and Drug Administration for that indication, as long as the drug is recognized for the treatment of that indication in one of the standard reference compendia (the United States Pharmacopeia Drug Information or the American Hospital Formulary Service Drug Information) or in peer-reviewed medical literature. Coverage includes Medically Necessary services given in connection with the administration of the drug. charges made for dental varnish are covered for children up to age four only at 100% with no deductible/copay. GM6000 INDEM62 V26 M charges made for medical and surgical services for the treatment or control of clinically severe (morbid) obesity as defined below and if the services are demonstrated, through existing peer reviewed, evidence based, scientific literature and scientifically based guidelines, to be safe and effective for the treatment or control of the condition. Clinically severe (morbid) obesity is defined by the National Heart, 29

30 Lung and Blood Institute (NHLBI) as a Body Mass Index (BMI) of 40 or greater without comorbidities, or a BMI of with comorbidities. The following items are specifically excluded: medical and surgical services to alter appearances or physical changes that are the result of any medical or surgical services performed for the treatment or control of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether or not they are prescribed or recommended by a Physician or under medical supervision. GM BNR1 orthognathic surgery to repair or correct a severe facial deformity or disfigurement that orthodontics alone can not correct, provided: the deformity or disfigurement is accompanied by a documented clinically significant functional impairment, and there is a reasonable expectation that the procedure will result in meaningful functional improvement; or the orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease or; the orthognathic surgery is performed prior to age 19 and is required as a result of severe congenital facial deformity or congenital condition. Repeat or subsequent orthognathic surgeries for the same condition are covered only when the previous orthognathic surgery met the above requirements, and there is a high probability of significant additional improvement as determined by the utilization review Physician. GM BNR10 On-line physician visits through an approved internet-based intermediary (dependent upon product and availability). Early Intervention Services Charges for early intervention services for members ages birth to 36 months of age with an identified developmental disability or delay. GM BNR5M V1 Clinical Trials charges made for routine patient services associated with cancer clinical trials approved and sponsored by the federal government. In addition the following criteria must be met: the cancer clinical trial is listed on the NIH web site as being sponsored by the federal government; the trial investigates a treatment for terminal cancer and: (1) the person has failed standard therapies for the disease; (2) cannot tolerate standard therapies for the disease; or (3) no effective nonexperimental treatment for the disease exists; the person meets all inclusion criteria for the clinical trial and is not treated off-protocol ; the trial is approved by the Institutional Review Board of the institution administering the treatment; and coverage will not be extended to clinical trials conducted at nonparticipating facilities if a person is eligible to participate in a covered clinical trial from a Participating Provider. Routine patient services do not include, and reimbursement will not be provided for: the investigational service or supply itself; services or supplies listed herein as Exclusions; services or supplies related to data collection for the clinical trial (i.e., protocol-induced costs); services or supplies which, in the absence of private health care coverage, are provided by a clinical trial sponsor or other party (e.g., device, drug, item or service supplied by manufacturer and not yet FDA approved) without charge to the trial participant. Genetic Testing charges made for genetic testing that uses a proven testing method for the identification of genetically-linked inheritable disease. Genetic testing is covered only if: a person has symptoms or signs of a genetically-linked inheritable disease; it has been determined that a person is at risk for carrier status as supported by existing peer-reviewed, evidencebased, scientific literature for the development of a genetically-linked inheritable disease when the results will impact clinical outcome; or GM BPT1 the therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the existing peer- 30

31 reviewed, evidence-based, scientific literature to directly impact treatment options. Pre-implantation genetic testing, genetic diagnosis prior to embryo transfer, is covered when either parent has an inherited disease or is a documented carrier of a geneticallylinked inheritable disease. Genetic counseling is covered if a person is undergoing approved genetic testing, or if a person has an inherited disease and is a potential candidate for genetic testing. Genetic counseling is limited to 3 visits per calendar year for both preand postgenetic testing. Nutritional Evaluation charges made for nutritional evaluation and counseling when diet is a part of the medical management of a documented organic disease. Internal Prosthetic/Medical Appliances charges made for internal prosthetic/medical appliances that provide permanent or temporary internal functional supports for nonfunctional body parts are covered. Medically Necessary repair, maintenance or replacement of a covered appliance is also covered. GM BPT2 Home Health Services charges made for Home Health Services when you: (a) require skilled care; (b) are unable to obtain the required care as an ambulatory outpatient; and (c) do not require confinement in a Hospital or Other Health Care Facility. Home Health Services are provided only if CG has determined that the home is a medically appropriate setting. If you are a minor or an adult who is dependent upon others for nonskilled care and/or custodial services (e.g., bathing, eating, toileting), Home Health Services will be provided for you only during times when there is a family member or care giver present in the home to meet your nonskilled care and/or custodial services needs. Home Health Services are those skilled health care services that can be provided during visits by Other Health Care Professionals. The services of a home health aide are covered when rendered in direct support of skilled health care services provided by Other Health Care Professionals. A visit is defined as a period of 2 hours or less. Home Health Services are subject to a maximum of 16 hours in total per day. Necessary consumable medical supplies and home infusion therapy administered or used by Other Health Care Professionals in providing Home Health Services are covered. Home Health Services do not include services by a person who is a member of your family or V1 your Dependent's family or who normally resides in your house or your Dependent's house even if that person is an Other Health Care Professional. Skilled nursing services or private duty nursing services provided in the home are subject to the Home Health Services benefit terms, conditions and benefit limitations. Physical, occupational, and other Short-Term Rehabilitative Therapy services provided in the home are not subject to the Home Health Services benefit limitations in the Schedule, but are subject to the benefit limitations described under Short-term Rehabilitative Therapy Maximum shown in The Schedule. GM BPT104 Hospice Care Services charges made for a person who has been diagnosed as having twelve months or fewer to live, due to Terminal Illness, for the following Hospice Care Services provided under a Hospice Care Program: by a Hospice Facility for Bed and Board and Services and Supplies; by a Hospice Facility for services provided on an outpatient basis; by a Physician for professional services; by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling; for pain relief treatment, including drugs, medicines and medical supplies; by an Other Health Care Facility for: part-time or intermittent nursing care by or under the supervision of a Nurse; part-time or intermittent services of an Other Health Care Professional; GM6000 CM34 physical, occupational and speech therapy; FLX124V38M medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and laboratory services; but only to the extent such charges would have been payable under the policy if the person had remained or been Confined in a Hospital or Hospice Facility. The following charges for Hospice Care Services are not included as Covered Expenses: for the services of a person who is a member of your family or your Dependent's family or who normally resides in your house or your Dependent's house; 31